HEWs in the Study Setting

Official information obtained from the Woreda Health Office indicates that woreda 5 of AradaSub-city has a population of 21,023 of which 11,142 are female. Number of pregnant women for the year 2012/13 is estimated at 388 while number of children aged above 5 years is 1194.

The Woreda 5 Health Office has 16 HEWs engaged in mainly raising community awareness on the health packages and report on a daily basis their activities and problems encountered at the work sites. Working under two supervisors and the Head of the Woreda Health Office, these HEWs start each workday with a brief evaluative meeting with their supervisors at 8 am, 30 minutes earlier than the official beginning time for the other staff. Although meetings were off-limit to the researcher, tension was often observed after the end of these meetings with some HEWs feeling too much burden from supervisors’ expectations and requirements from these junior nurses.

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Under UHEP, each HEW is expected to train and recruit 500 model families (largely female model mothers) within the community and each model mother in turn will recruit five model mothers under her, and so on. In the end, the Program aims to cover the community at large so as to enhance community health, prevent diseases and improve health seeking behaviour.

However, training sessions and awareness raising programs do not always happen as scheduled as the community members often engage in their “more pressing matters for their subsistence” (HEW1). The five HEWs approached for this study all have recurrently rescheduled their sessions with communities to weekends or to times outside working hours for which they do not receive any allowance or other forms of benefit except their salary and housing allowance ranging in total from 1283 Ethiopian birr ($71.3) to 1354 Ethiopian Birr ($75.2). These extra engagements without extra payment, I noticed, were not necessarily practiced from personal conviction of the HEWs but often to “reach the quota assigned for us (number of model mothers) that we are required to cover in a given period” (Interview HEW1). It is not uncommon, a HEW said, to “go out in the site with your work plan but end up meeting community members in some lengthy dispute. Then, you leave your work aside and try to mediate between them” (HEW1 interview). Often, a work plan can be a general guide but its implementation is greatly influenced by factors such as community interest, trust in the Program and convenience of timing for communication in the face of poor communities’ hustle and bustle to make ends meet.

The HEWs are generally positive to the Program. They claim to have witnessed people showing more interest to go to health facilities even for health concerns they might have previously considered unimportant. They also believe that a lot of the improvements in health indicators for maternal health care, child survival, HIV prevalence, etc correlate with UHEP and its community participating packages. However, their frustration about its being overambitious is immediately evident. They find it daunting to try to improve community health mainly through changing health seeking behaviour without necessarily addressing the material conditions in these communities. It is “not realistic to teach them about keeping healthy while the content of their [common] toilet is overflowing. We try to take such matters to relevant offices and that is a challenge of its own kind.”(Interview HEW3). Hence the interventions sometimes become inappropriate to the conditions of the targeted communities.

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The interaction between the HEWs and their community recruits has not always been smooth.

Even this researcher witnessed two model mothers who were not on speaking terms with their HEWs. The mothers, according to my HEW informants, were cross with the HEWs because they were not selected by the nurses for a training organized by an NGO. That was not because they were necessarily interested in the training per se, but because they missed “the small allowance” behind it. Such competitions for the rare material benefit from the Program is not limited to that incident, but rather what seems to often drive active participation among some mothers (Interview HEW1, HEW2). It appears that UHEP’s maternal health interventions are largely informative that they do not live up to material expectations of beneficiaries.

Trust is also an issue for the interaction between communities and their HEWs. Although the community generally shows a great deal of respect to what the HEWs are doing, they “doubt our competence”, complained an informant, and added:

The community have a problem [with us]. They say ‘ok’ when we tell them on the spot. They lie about going to a health facility. They don’t take us seriously [professionally]. They think only a nurse sitting in a health centre in her white gown is qualified (HEW1).

While it was not clear what the source of disinterest was, the ‘Come Drink Coffee’ session attended by this researcher indeed well tallies with the HEW’s lamentation about not being taken seriously. The maternal health session which was passively attended by about a dozen of mothers was almost reduced to a conversation between the teaching HEW and one active participant who, in her own words, “stopped giving birth”. Not only the session was seriously unattended by the rest of the participants side-talking while sipping their coffee, even the woman who seemed very interested in the teaching cast her doubts on some of the tips from the HEW. On one occasion she told the HEW that “as far as my experience goes, you better not advice people to use ‘yemikeberewin’ [implanon and depo-provera]. The pills are much better”, and perhaps out of discontent, the HEWs briefly and quickly responded, “it depends on the individual. It’s up to the mother to choose” (Observation from the Come drink Coffee Session).

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HEW holding a maternal health session with model mothers

UHEP is a narrative of both success and frustration for the Head of the Woreda Health Office, too. Although he understands that research is scant on the contribution of UHEP to enhanced community health, he seemed to have little doubt that the Program has a great share in changing communities’ health seeking behaviour. He stated, through UHEP, “we have created a society that appreciates hygiene; created awareness on stigma and discrimination and the maternal and child morbidity and mortality rates have decreased” (Interview with Head of Woreda 5 Health Office and the Woreda’s Chief Coordinator of UHEP). He also remarked that the HEP in general is a very appropriate vehicle to meeting the health MDGs.

However, his confident remark was deeply overshadowed later as our conversation developed especially when he discussed his community’s level of participation in the Program.

UHEP was introduced following the success of the rural HEP. [But] the rural HEP is much more effective than our urban version. UHEP has nurses as HEWs because the urban population is assumed to have generally better education and a higher level of awareness…Because of better exposure to media and other sources, urban dwellers think they know and they think they are more aware of health issues [but they are not]. They show

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negligence [to the discussions under the Program]. They have not internalized the packages (Interview with Head of Woreda 5 Health Office and the Woreda’s chief coordinator of UHEP).

The Head also appeared to have envied the obligatory skilled birth attendance that he witnessed under HEP in which “a husband receives penalities if his wife delivers their baby at home, so he has to take her to a health center (ibid).

However, he also realizes the difficulty of mobilizing the mothers without responding to some of their practical challenges that relate to their poor livelihood. He attaches high hopes of change with stronger collaboration with NGOs specially in providing nutritious food for

“malnourished children. We’re identifying them and will refer them to NGOs [for support].

We’re also introducing nutrition for children to be provided at the health centres” (Interview with Head of Woreda 5 Health Office and the Woreda’s chief coordinator of UHEP).